PJ Online | MM Features (Ways to reduce the use of anxiolytic and hypnotic drugs in primary care)

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Medicines Management
Issue no 2, p11-12
March/April 2002

Features

Ways to reduce the use of anxiolytic and hypnotic drugs in primary care

Suzanne Berry describes how one doctors' practice has reduced the prescribing of hypnotics and anxiolytics by a third. This included sending letters to patients to spell out the benefits to them

Doctors' names
Surgery address

Date

Dear Patient's name,

I am writing to you because I note from your records that you have been taking sleeping tablets for some time now. We, your doctors, are concerned about this kind of medicine when it is taken over a long time. Our concern is that the body can get used to these tablets so that they no longer work properly. As well, long-term use of this medicine can cause anxiety and sleeplessness.

What we are trying to do is reduce the amount of tablets you are taking with a possibility of stopping them at a future date. But we do not want you to stop taking them suddenly as this could cause unpleasant effects.

Our aim is to make you less dependent on the tablets. We would like you to consider only taking the tablets when absolutely necessary. To encourage you to do this we are reducing the amount of tablets on your prescription. Please feel free to come and discuss this with us in the near future.

Yours sincerely

Doctor's name

The mental health national service framework requires doctors to justify prescribing outside clinical guidelines. The use of hypnotics and anxiolytics is measured nationally as a high level performance indicator. These drugs are only recommended for short-term use, ie, between two and four weeks, yet are frequently continued long-term. Long-term use can cause anxiety, sleeplessness and falls.

One practice in the west Midlands had a high proportion of patients dependent on these drugs and, inspired by Northern and Yorkshire regional drug and therapeutics centre drug update no 14 (Feb 2001), wanted to try and reduce this.

The idea was quite simple: all patients taking temazepam, nitrazepam, diazepam and the "Z" drugs (zopiclone, zolpidem etc.) were sent a letter explaining the disadvantages of taking these medicines regularly and that to stop them, they would need to be reduced slowly. (A sample letter is opposite but it could easily be adapted to suit different practices.)

The GPs also decided that they would like to reduce the quantity of these drugs prescribed by half so that patients would have fewer tablets in their houses. They could still continue on them, but would be encouraged to discuss when that was appropriate with their GP.

The practice pharmacist discussed with the GPs how patients could be supported to withdraw slowly and be swapped to diazepam where appropriate. For patients over 85 years old, the GPs decided on an individual basis what action to take and whether or not to send them a letter.

In total 173 patients were sent letters and had their medication reduced to a two-week supply. Six months later, looking at a sample of patients, 26 per cent had stopped their medication altogether, 39 per cent continued to receive half the original dose once a month and 35 per cent continued on them regularly. ePACT data confirmed a reduction: the quantity of hypnotics and anxiolytics prescribed in this practice has reduced by a third compared to last year. So what lessons can other pharmacists and practices learn from this experience?

1. Have a go at what others have done before

As it worked for us, it may work for you. If it does not, then at least you have tried and you can share and discuss with others reasons why it might not have.

Comments from practice staff:

Nurse: The information given to both the nurses and patients was good. Good explanations were given including the reasons why and the patients responded very well

Receptionist: Most people accepted it as the doctors say so

GP: We were surprised and encouraged that this took very little extra appointment time than anticipated. We also reviewed patients we hadn't seen for some time. We were surprised at the proportion who actually wanted to give up.

Practice manager: I felt that the audit was not going to be a success and am pleasantly surprised that it was

Practice pharmacist: It was time-consuming to change the prescriptions to 2/52 supply and send the letters but once I had talked to a couple of patients about coming off, I knew it would be worthwhile. I am so surprised that so many have stopped and also that 40 per cent have halved their dose.

2. Listen to the practice administrative staff and ask their advice about how to approach patients

I was too enthusiastic and wanted to send all the letters at once. The practice recommended sending about 35 letters a week over three months so that it would only mean a few extra appointments for the doctors each week. Feedback each week from practice staff meant that the wording of the letter was changed four times to make it clearer for patients. Comments from practice staff can be seen in the panel on the right.

3. Tell local community pharmacists what you are doing

Community pharmacists needed to know what was going on because they would potentially have to deal with complaints from patients. I explained why the project was being done and asked for their support. The clinical information given to the GPs about reducing slowly was shared with the pharmacists, too, as were the excellent results.

4. Do not give up

When you hear about patients moaning about something you are trying to change, it can be discouraging. Instead, share a success story at the practice meeting to keep spirits up.

5. Do not assume the GPs know everything

It was useful revision to go over the BNF guidelines for swapping to diazepam and reducing it.

Discussion

The project has proven to be successful at reducing the prescribing of hypnotics and anxiolytics to patients in one practice. These results compare favourably with a number of published audits. Reducing the dose of these addictive drugs has many benefits. These include lowering the incidence of side-effects among which are potentially disabling falls by patients.

Suzanne Berry is deputy prescribing adviser for North Birmingham Primary Care Group